The Beak Is The Breadcrumb: Tarsal Coalition and the Pain That Points the Wrong Way

The Soft Tissue Cost of Testosterone

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] As testosterone injections become normalised for strength, physique and recovery, emerging research is raising uncomfortable questions about injuries to ligaments, tendons and surgical repairs. Testosterone has had a rebrand. For many people, it no longer seems to sit in the same mental category as ‘performance-enhancing drug’ or ‘anabolic steroid’. It has become wellness-adjacent. Gym-adjacent. Recovery-adjacent. More muscle. Better physique. Faster recovery. More confidence. Back in the gym sooner. Sounds neat. Until the ACL goes. Or the Achilles. Or the biceps tendon. Or the rotator cuff. This is the bit of the testosterone conversation that feels strangely quiet. The online discussion often starts and ends with body composition, energy, libido and performance. But for those of us working in musculoskeletal practice, there is another question worth asking. What is happening to the tissues that have to tolerate all this extra force?

Is this the writing on the wall for First Contact and Advanced Practitioners in the NHS?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] In May 2026, the British Medical Association, the largest doctors’ union in the UK, published the findings of a survey of over 5,000 doctors on the role of Advanced Practitioners (APs), with 81% saying that the way APs currently work poses a risk to patient safety. This was reflected in a new position statement from the Royal College of Physicians, suggesting that replacing doctors with other roles created ‘a real risk of fragmented care and harm to patient safety’. To understand the degree of antipathy against APs, we must go back to the beginning (This is where, in a film, the swirly spiral denotes we are going back in time (you can hum the atmospheric tune yourselves…)). The Origin Story It’s the millennium, and there is a steady but unmistakable shift from a model of care that was in place from the inception of the NHS in the 1940s to when I qualified in the early 2000s. The 1-in-2 on-call rotas are rapidly becoming a thing of the past as Modernising Medical Careers and the European Working Time Directive from 2004 onwards reduced the average number of hours worked by doctors and the old ‘firm’ structures (Consultant, Registrar, SHO, HO etc) made way for newer ways of working. Whilst the number of hours doctors worked decreased, the population continued to age and grow, creating a tidal wave of increasing complexity and acuity, placing services under unprecedented demand. The number of patients registered with NHS GPs in England grew significantly, from roughly 50 million in 2020 to just under 64 million by 2025. To meet this growing demand, the Health Foundation suggests that a further 3,500 GPs will be needed by 2031. But it takes a long time to train a doctor; 10+ years as a minimum for GPs, and the number of full-time equivalent GPs has dropped by 458 since 2015. Step into the breach: non-doctor roles. By the time of the NHS long-term plan in 2019, early pilots of first-contact physiotherapists had shown they could be useful members of the primary care team. In 2020, the National Evaluation of the First Contact Practitioner (FCP) model of primary care evaluated 240 FCPs from 40 services in England and found that FCPs were acceptable to patients, produced positive outcomes, and reduced GP workload [1].

Physiotherapy Education: Getting Graduates Ready for What Exactly?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] Are physiotherapy graduates ready for practice? If you’ve ever asked this question, you’re not alone. The quick answer? No. But they’re not meant to be. The longer answer? Well that starts in 1894… The Start of Physiotherapy Education [Image 1: Almeric Paget Military Massage Corps [8]] Four women drew a line. Stories in the national press were warning the public about ‘unscrupulous’ people offering massage as cover for something else entirely. They set up the Society of Trained Masseuses because the work deserved better. They established a curriculum and examinations. Standards mattered from the very beginning. What followed was a profession that proved itself through necessity. When World War I broke out in 1914, physiotherapists were quickly deployed to military hospitals. They went where the need was greatest. This community instinct, going where people are and working in the places where health matters, was not a policy position. It was simply what the profession did. Recognition followed practice: it always has. So, what does ‘being ready’ really mean for a profession that has always gone where people needed it, and found a different answer every time? Ownership In its earliest years, the physiotherapy classroom and clinic were never far apart. Learning happened close to the work, even without a formal structure. By 1955 that structure arrived in the form of a national syllabus for physiotherapy [1]. Every UK student physiotherapist followed this one pathway - a three-year curriculum taking place in schools attached to a hospital. After an initial six months of training, they spent 1,500 hours or more treating patients under the supervision of qualified physiotherapists, accounting for 10-30 contact hours a week. The final exams were entirely practical, and they assessed and treated patients in the hospital. Assessment papers were sent directly to the professional body to be moderated against a national standard. There was no gap between education and practice because the two had never been separated, everything taking place under one roof. [Image 2: 1955 CSP Syllabus [1]] Interestingly, the syllabus described the preparation of students as “a graduated process of education leading to admission to membership.“ Not admission to a qualification, but admission to a community. To qualify was to join. The professional body set the standards, ran the examinations, and held the membership. Regulation and professional identity were, in practice, the same thing.

The Beak Is The Breadcrumb: Tarsal Coalition and the Pain That Points the Wrong Way

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] A 24-year-old middle distance runner came in with dorsal midfoot pain – just distal to a little lump at the dorsal talonavicular joint. By the time she reached me she’d done the full lap. Foot strengthening. Mobilisations. Expensive custom orthotics. Shockwave. Dry needling. None of it moved the needle. Her running told the same story every time. Fine off the line but pain starting 2 to 3 km into a 5 km run. Every session. She’d already had an MRI from a previous healthcare provider. In a classic case of ‘junk in = junk out’ - there wasn’t much on the report. The referral: ‘ankle pain’, though ideally it would have read ‘dorsal midfoot in runner near palpable prominence at talonavicular joint’. C’mon people…. Radiologists deserve some stories sometimes! Despite an allegedly radiologically-boring midfoot, the report did give away the big clue in the hindfoot: an osseous subtalar tarsal coalition across the sustentaculum tali (without significant stress reaction). Nobody paid it much attention, presumably because nobody was sure what it meant. The beak is a symptom, not a diagnosis A dorsal talar beak is a bony outgrowth on the upper aspect of the talar head, projecting toward the talonavicular joint. It is a traction osteophyte. It forms where the dorsal talonavicular ligament and capsule pull repeatedly on the talus; the foot’s attempt to remodel around mechanics that have gone wrong upstream [1]. The alternative explanation is mechanical: the navicular rides up over the talar head and lifts the periosteum, and bone fills the gap [2]. Either way, the beak is not the villain, it is the breadcrumb. The question worth asking is what is driving it. In a young adult the answer is often a restricted subtalar joint, and the usual culprit is tarsal coalition. What a coalition actually is

Chewy and Jim - Navigating The System

Chewy and Jim are back - the lads were evaporating during the recording this month as the weather matched their opinions for heat… Chewy and Jim is best watched in full via the video above (so you can watch them melt in real time) or you can listen on the usual podcast players. In this recording, Chewy and Jim cover consultations from good to bad and their experiences sitting on both sides. “You can be as good medically or with your assessment as you want, but if you can’t guide the consultation and keep the patient on board and engaged, they’re going to leave unhappy and not getting what they want out of it.” - Jim It’s a real skill to run an effective consultation and this becomes really challenging in situations of complexity or system restrictions (lack of time). Unfortunately when this skill is lacking or not applied, the whole thing falls apart and people leave disappointed and frustrated. Chewy and Jim describe stark contrasts between well run and poorly run consultations and it makes a huge difference to the experience. “The actual technical aspect of conducting a consultation is a really overlooked skill.” - Jim Chewy and Jim get into a discussion about the variables that go into this particular skill and it is not just experience. Appropriate feedback mechanisms, training, and practice are all of vital importance to develop the ability to run the consultation effectively AND sensitively. Without appropriate challenge for poor practice and ongoing complacency that this is not a skill that requires development, variation in practice widens and can cause significant problems for those people attempting to navigate the health systems they require. “Variation in care standards can be refined. It shouldn’t just be accepted that sometimes you get the biscuit muncher and sometimes you get the brilliant clinician.” - Chewy This is a really difficult skill to improve and we will never master it fully; different components of it require work for individuals, Chewy for example never shuts up and Jim can’t wait to end every conversation as quickly as possible… Embracing your own individuality but holding it to within appropriate professional boundaries is the balance to aim for. Never go full Chew! Jim points out that the likely training method for working on this skill is roleplay and that induces massive cringe responses in most but it is an absolute necessity in order to receive instant peer feedback and implement improvements outside of the clinic room that you can take with you. Embrace it and leave your cringe at the door: improvements in this skillset will help every aspect of the clinical consultation including the outcomes. Chewy and Jim are nothing if not desperate for these rants to be clinically applicable tomorrow… Dos and Don’ts for consultations: * Introduce yourself and explain your role/Don’t leave patients guessing who you are. * Set expectations early. * Guide the conversation without being rude/Don’t interrupt abruptly. * Don’t start the consultation distracted or disengaged. Would Chew Rather speak only in technical jargon or only in complete lay language? The answer will likely surprise you… Let us know your answer. If you have any ‘Would Chew Rather?’ or ‘Who Are Chew?’ questions put them in the comments or email them to us mskmag@physio-matters.com This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe [https://mskmag.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]